Prof. Dr. Shyam P Lohani

The countries around the globe celebrated World Hepatitis Day 2020 on 28th July with the theme of a Hepatitis-free future. To achieve the 2030 elimination targets for Hepatitis, the day was marked to promote the importance of prevention of mother-to-child transmission of Hepatitis B virus (HBV), develop and launch new guidance. The day, therefore, called for increased thrust for domestic and international funding and programmes for preventing the mother-to-child transmission of the virus as well as increasing access to Hepatitis prevention, testing, and treatment services.
Hepatitis B is a global public health problem with the potential to cause chronic infection leading to cirrhosis and liver cancer. This life-threatening illness puts people at high risk of deaths. We can almost avert the development of chronic disease and liver cancer by the use of the Hepatitis B vaccine which offers almost 100 per cent protections against the deadly killer virus.

Epidemiology
In 2015, about 257 million people were living with chronic Hepatitis B infection (WHO, 2020). In the same year, some 887,000 people died of cirrhosis and hepatocellular carcinoma worldwide. The prevalence of Hepatitis B infection in the South Asia Region is estimated at two per cent of the general population (WHO, 2020). In Nepal, the nationwide prevalence of Hepatitis B stands at 0.9 per cent, which is lower in comparison to other nations in the region. But the prevalence of Hepatitis B infection among other most at-risk groups is significantly higher such as among injecting drug users (5.5 per cent) and people living with HIV and AIDS (4.4 per cent). Several seroprevalence studies in Nepal have found a higher prevalence of Hepatitis B infection among the indigenous population.
In another estimation by WHO, around 27 million people (10.5 per cent of the total population estimated to be living with Hepatitis B in the world) were aware of their infection, while 4.5 million (16.7 per cent) of the people diagnosed were on treatment. With the availability of the highly effective vaccine, the proportion of children under five years of age who are chronically infected with Hepatitis B infection dropped below one per cent in 2019 from around 5 per cent during the pre-vaccine era from the 1980s to early 2000s (WHO, 2020).
The main risk factor for acquiring HBV infection worldwide is promiscuous unprotected sexual activity, while other main risk factors have a different impact on different geographical areas. HBV infection is most frequently acquired at birth from Hepatitis B e-antigen (HBeAg) positive mothers or through household contacts in early childhood in countries with intermediate/high endemicity, with a high rate of progression to chronicity that helps to maintain the high levels of endemicity. In countries with low HBV endemicity, the major risk factor for acquiring HBV infection is the sharing of needles and other equipment between intravenous drug users, which causes the infection to remain confined to this at-risk population.
The widespread HBV infection, its frequent evolution into chronicity with the possibility of developing liver cirrhosis and hepatocellular carcinoma, and its progression to death in patients, who do not undergo successful liver transplantation, have called for extensive HBV vaccination campaigns and effective therapeutic measures.

Measures
It has been found that perhaps one of the largest barriers to eradication was diagnosis; only 10.5 per cent of the 257 million people living with chronic Hepatitis B viral infection were aware of their status in 2015. To achieve the eradication goal, there is a critical need for new and affordable diagnostics that are also available in non-specialty centres. Furthermore, testing needs to be ramped up in populations at increased risk for viral hepatitis infections — people who inject drugs, homosexual men, and indigenous populations. Finding infection among the population is vital, though, as treatment is a second critical step in halting the spread of viral hepatitis infections.
The strategies for the prevention and control of Hepatitis B infection requires a comprehensive approach to preventing mother-to-child transmission through immunisation, safety measures in blood transfusion services, injection safety, and harm reduction services such as needle exchange programmes. Therefore, vaccination, blood screening at the transfusion centres, and awareness are key to combating Hepatitis B infections. Moreover, national prevention and control strategies should integrate Hepatitis B infection elimination along with HIV/AIDS and other sexually transmitted infections. The programmes should focus on those sections of the population that are most vulnerable to the transmission of the Hepatitis B virus.

Evidence-based policy
The international commitment on Sustainable Development Goals by 2030 to reduce 90 per cent new infections from occurring and 65 per cent decrease in mortality due to Hepatitis B infection is possible by formulating appropriate evidence-based policy, raising awareness, promoting partnerships with sufficient resources, increasing health equities, preventing transmission and scaling up of screening, care and treatment services at the health care centres throughout the country. It is also important not to underestimate the financial support to those with the infection. Hence, a large-scale nationwide epidemiological study aiming at finding the prevalence of Hepatitis B infection among the general population as well as among most at-risk groups become paramount to develop effective and financially viable policy and guidelines to achieve the goal of eliminating the infection.

(Prof. Lohani is the founder and academic director of Nobel College. lohanis@gmail.com)